Toe Fracture Management

Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. Toe fractures most frequently are caused by a crushing injury or axial force such as stubbing a toe. A toe fracture is a break in 1 or more of the bones in your toe.

It is most commonly caused by a direct blow to the toe. Joint hyperextension and stress fractures are less common. Most patients have point tenderness at the fracture site or pain with gentle axial loading of the digit.

Anteroposterior and oblique radiographs generally are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges and digits.

Referral is indicated in patients with circulatory compromise, open fractures, significant soft tissue injury, fracture-dislocations, displaced intra-articular fractures, or fractures of the first toe that are unstable or involve more than 25 percent of the joint surface.

Most children with fractures of the physis should be referred, but children with selected nondisplaced Salter-Harris types I and II fractures may be treated by family physicians. Stable, nondisplaced toe fractures should be treated with buddy taping and a rigid-sole shoe to limit joint movement.

Displaced fractures of the lesser toes should be treated with reduction and buddy taping. Patients with displaced fractures of the first toe often require referral for stabilization of the reduction.

Differential Diagnosis

The same mechanisms that produce toe fractures may cause a ligament sprain, contusion, dislocation, tendon injury, or other soft tissue injury. Radiographs often are required to distinguish these injuries from toe fractures. Stress fractures can occur in toes.

They typically involve the medial base of the proximal phalanx and usually occur in athletes. Stress fractures have a more insidious onset and may not be visible on radiographs for the first two to four weeks after the injury.

What are the signs and symptoms of a toe fracture?

Pain, redness, and swelling

Inability to bend or move your toe

Inability to walk or put weight on your toe

Toe is bent at an abnormal angle

How is a toe fracture treated?

Buddy tape: Your caregiver will put a small piece of gauze between the fractured toe and the toe next to it. Then he will tape your toes together. This helps support your broken toe and limit movement so it can heal.

Special shoe: You may need a special shoe or walking cast. This will protect your broken toe and limit movement so it can heal. The shoe may also make it easier for you to walk.

Medicine

NSAIDs: These medicines decrease swelling, pain, and fever. You can buy NSAIDs without a doctor’s order. Ask your caregiver which medicine is right for you, and how much to take.

Take as directed. NSAIDs can cause stomach bleeding or kidney problems if not taken correctly.

Antibiotics: You may need antibiotics if you have an open wound. This medicine helps fight or prevent an infection.

Td vaccine: This vaccine is a booster shot used to help prevent diphtheria and tetanus. The Td booster may be given to adolescents and adults every 10 years or for certain wounds and injuries.

Closed reduction: This is when caregivers put your bones back into their correct position without surgery.

Open reduction: This is done when a closed reduction does not work or you have ligament damage. An incision is made and the bones and ligaments are put back into the correct position.

Open reduction may include the use of wires, pins, plates, or screws. These help keep the broken pieces lined up so your toe can heal correctly.

What are the risks of a toe fracture?

You could get an infection or bleed more than expected after surgery. Even after treatment, your toe may not go back to the way it was before your injury. Without treatment, you may have trouble walking or playing sports.

How can I manage my symptoms?

Rest: Rest your toe so that it can heal. Return to normal activities as directed.

Ice: Ice helps decrease swelling and pain. Ice may also help prevent tissue damage. Use an ice pack, or put crushed ice in a plastic bag. Cover it with a towel and place it on your toe for 15 to 20 minutes every hour or as directed.

Elevate: Raise your toe above the level of your heart as often as you can. This will help decrease swelling and pain.

Prop your toe on pillows or blankets to keep it elevated comfortably.

When should I contact my caregiver?

Contact your caregiver if:

You have a fever.

Your pain does not go away, even after treatment.

Your toe continues to hurt even after it has healed.

You have questions or concerns about your condition or care.

When should I seek immediate care?

Seek care immediately or call 911 if:

Blood soaks through your bandage.

You have severe pain in your toe.

Your toe is cold or numb.

Care Agreement

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your caregivers to decide what care you want to receive.

You always have the right to refuse treatment. The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments.

Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

Indications for Referral

Patients with circulatory compromise require emergency referral. Toe fractures of this type are rare unless there is an open injury or a high-force crushing or shearing injury. Patients with open toe fractures or fractures with overlying skin necrosis are at high risk for osteomyelitis.

If there is a break in the skin near the fracture site, the wound should be examined carefully. If the wound communicates with the fracture site, the patient should be referred.

In some practice sites, family physicians manage open toe fractures; a discussion about the management of this type of injury can be found elsewhere.

Patients also may require referral because of delayed complications such as osteomyelitis from open fractures, persistent pain after healing, and malunion.

Fractures of The First Toe

Because of the first toe’s role in weight bearing, balance, and pedal motion, fractures of this toe require referral much more often than other toe fractures.

Deformity, decreased range of motion, and degenerative joint disease in this toe can impair a patient’s functional ability.

Referral is recommended for patients with first-toe fracture-dislocations, displaced intra-articular fractures, and unstable displaced fractures (i.e., fractures that spontaneously displace when traction is released following reduction).

Referral also is recommended for children with first-toe fractures involving the physis. These injuries may require internal fixation.

Referral should be strongly considered for patients with nondisplaced intra-articular fractures involving more than 25 percent of the joint surface.

These fractures may lose their position during follow-up. Even if the fragments remain nondisplaced, significant degenerative joint disease may develop.

Fractures of The Lesser Toes

Although referral rarely is required for patients with fractures of the lesser toes, referral is recommended for patients with open fractures, fracture-dislocations, displaced intra-articular fractures, and fractures that are difficult to reduce.

Referral is recommended for children with fractures involving the physis, except nondisplaced Salter-Harris type I and type II fractures.

Patients with unstable fractures and nondisplaced, intra-articular fractures of the lesser toes that involve more than 25 percent of the joint surface usually do not require referral and can be managed using the methods described in this article.

Complications

A common complication of toe fractures is persistent pain and a decreased tolerance for activity. Pain that persists longer than a few months may indicate malunion, which may limit a patient’s future activities significantly.

Toe fractures, especially intra-articular fractures, can result in degenerative joint disease, and osteomyelitis is a potential complication of open fractures.